Archive for August, 2013

Kegel Exercises Are Also For Men-Controlling Urinary Incontinence

August 30, 2013

For decades, women have been performing pelvic floor exercises, or Kegel exercises to strengthen their pelvic floor muscles and help control urinary incontinence. Now these same exercises can be performed for men who have the same problem.

How to do your Pelvic Floor Muscle Exercises
Men experience a variety of problems with their urinary system, leading to unwanted leakage of urine. Often this is due to a weakness of the muscles of the pelvic floor, which have an important function in preventing these troublesome conditions. In particular, pelvic floor exercises have been shown to be effective following surgery on the prostate and when men experience a dribble after passing water.
The floor of the pelvis is made up of layers of muscle and other tissues stretching from like a hammock across the floor of the pelvis and attached to your tail bone (coccyx) at the back and to the pubic bone in front. The urethra (bladder outlet) and the rectum (back passage) pass through the pelvic floor muscles. The hammock of muscles and other tissues supports the bladder and the bowel and plays an important role in bladder and bowel control.

Why the Pelvic Floor Muscles get Weak?
The pelvic floor muscles can be weakened by:
Operations on the prostate gland where the nerves to muscles of the pelvis may be injured or damaged.
a chronic cough, such as smoker’s cough or chronic bronchitis or asthma being overweight

Pelvic Floor Muscle Exercises?
You can improve control of your bladder and bowel by doing exercises to strengthen your pelvic floor muscles. These exercises may also be useful in conjunction with a bladder retraining program aimed at improving bladder control in people who experience the urgent need to pass urine frequently and may not always “make it in time”.

How to Identify your Pelvic Floor Muscles?
The first thing to do is to identify correctly the muscles that need to be exercised.
1. Sit or lie comfortably with muscles of your thighs, buttocks and abdomen relaxed.
2. Tighten the ring of muscle around the back passage as if you are trying to control diarrhea or wind. Relax it. Practice this movement several times until you are sure you are exercising the correct muscle. Do not hold your breath: keep breathing normally. You need to concentrate on using the correct muscles.

Do not tighten your buttocks or thighs. Some people find they pull in the lower stomach muscles as well and this is OK because the muscles are helping one another .
3. In order to contract your pelvic floor muscles it may help to imagine you are passing urine and trying to stop the flow mid-stream, then restarting it. If your technique is correct, each time that you tighten your pelvic floor muscles you may feel the base of your penis move up slightly towards your abdomen.
4. If you are unable to feel a definite squeeze and lift action of your pelvic floor muscles, you should seek professional help to get your pelvic floor muscles working correctly. Even men with very weak pelvic floor muscles can be taught these exercises by a physiotherapist or continence advisor with expertise in this area. See “Seeking Help” below.

Doing Your Pelvic Floor Muscle Exercises
Now that you can feel the muscles working, you can start to exercise them:
1. Tighten and draw in strongly the muscles around the anus and the urethra all at once. Lift them up inside. Try and hold this contraction strongly as you count to five, then release slowly and relax for a few seconds. You should have a definite feeling of “letting go”.
2. Repeat (“squeeze and lift”) and relax. It is important to rest in between each contraction. If you find it easy to hold the contraction for a count of five, try to hold for longer – up to ten seconds.
3. Repeat this as many times as you are able up to a maximum of 8-10 squeezes. Make each tightening a strong, slow and controlled contraction.
4. Now do five to ten short, fast, but strong contractions, pulling up and immediately letting go.
5. Do this exercise routine at least 3-4 times every day. You can do it in a variety of positions – lying, sitting, standing, walking.
6. While doing the exercises:
DO NOT hold your breath.
DO NOT push down instead of squeezing and lifting up.
Do your exercises carefully. The quality is important. Fewer good exercises will be more beneficial than many half-hearted ones.

Make the Exercises a Daily Routine
Once you have learned how to do these exercises, they should be done regularly, giving each set your full attention. It might be helpful to have regular times during the day for doing the exercises – for example, after going to the toilet, when having a drink, when lying in bed. You will wish to tighten your pelvic floor muscles also while you are getting up from a chair, coughing or lifting. Some men find that by tightening before they undertake such activities they assist themselves in regaining control.

Bottom Line: Good results take time. In order to build up your pelvic floor muscles to their maximum strength you will need to work hard at these exercises. You will probably not notice an improvement for several weeks or even a few months. But remember no Olympic champion developed a physique like a Greek god overnight!

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Can’t Get It Up-It May Just Be In Your Head If the mind is crazy….the penis can be lazy!

August 28, 2013

When I went to medical school, the party line was that most men with impotence had a psychological cause of their inability to engage in sexual intimacy. Now, the situation is reversed and most men have ED or impotence as a result of physical causes, i.e., decrease in the blood supply to the penis, hormone deficiencies, or nerve problems. However, 10-20% are still due to emotional causes.

Emotional causes are often a secondary reaction to an underlying physical cause. In some cases, the psychological effects of ED may stem from childhood physical abuse or sexual trauma. However, the most common psychological causes of ED include:

Stress can be job-related, money-related, or the result of marital problems.

Once a man experiences ED, he may become overly worried that the problem will happen again. This can lead to “performance anxiety,” or a fear of sexual failure, and consistently lead to ED.

A man may feel guilty that he is not satisfying his partner.

A common cause of ED, depression affects a person physically and psychologically. Depression can cause ED even when a man is completely comfortable in sexual situations. Drugs used to treat depression may also cause ED.

Low self-esteem can be due to prior episodes of ED (thus a feeling of inadequacy) or can be the result of other issues unrelated to sexual performance.

Indifference to sexual intimacy may come as a result of age and a subsequent loss of interest in sex, be the result of medications or stemming from problems in a couple’s relationship.

Let the truth be told: all men at one time or another will experience ED. Only if the problem becomes persistent, i.e., occurs more than half the time — or becomes a source of distress for you or your partner should you be concerned and consider seeking medical advice and treatment. Most men with ED due to either psychological or physical causes can be helped and even cured. I suggest you have a discussion with a doctor if you are “striking out” more than half the time. I can’t promise you a home run every time, but I can tell you that you can be helped.

Common Causes of Infertility in Men

August 28, 2013

Sperm making contact with egg

Sperm making contact with egg


About 10 percent of reproductive-age couples in the United States will have difficulty getting pregnant. About 30 percent of cases are due to fertility problems in the man, 30 percent to fertility problems in the woman, and the rest to unexplained causes or multiple factors involving both partners.

If you’ve had regular, unprotected sex for more than a year (or six months if you’re over 35) without conceiving, see your doctor. The National Infertility Association says at least half of those who have an infertility evaluation and treatment will be able to have a successful pregnancy.

A reproductive urologist can identify male fertility issues, recommend treatment options, and help couples decide which options to pursue. You also may want to see a genetic counselor. Sometimes, there’s a genetic reason for male infertility that could be passed down to children. A genetic counselor can help couples understand their options for conceiving.

Read on to learn about the common causes of infertility and available treatments. Keep in mind that success rates may vary because one couple can have multiple fertility problems.

Lifestyle factors. Making healthy choices can improve your fertility. You may be at greater risk of having trouble conceiving if you:

• Smoke;
• Drink alcohol heavily; Use drugs;
• Take anabolic steroids;
• Take certain medications, including testosterone replacement therapy;
• Have been treated for cancer;
• Have poor nutrition;
• Are significantly over- or underweight;
• Are exposed to toxins, such as pesticides or lead.

If you have any of these risk factors, be sure to tell us about it during your consultation.

Blockages. A small percentage of men have a blockage in their ejaculatory duct that prevents sperm from getting into ejaculate fluid. If your vas deferens or epididymis tubes are blocked or damaged, they can prevent your sperm from getting to your partner’s egg. Infection, injury, congenital defects, or a vasectomy could cause this blockage.
• Possible solutions: Surgery to repair an obstruction or reverse the vasectomy, or surgery to remove sperm for in vitro fertilization (IVF).
• Varicocele. Varicoceles (enlarged veins, similar to varicose veins, in the scrotum) raise the temperature in the testes, which may affect sperm production.
Possible symptoms: Some men have scrotal pain, and others have no symptoms. (The problem can be detected through a physical exam or ultrasound.)
Possible solutions: Surgery to repair the varicocele, artificial insemination, or IVF.

Irregular sperm. If you have little to no sperm, poor sperm motility (ability to move), or abnormally shaped sperm, your sperm may not be able to fertilize your partner’s eggs.
Possible solutions: fertility drugs; artificial insemination with donor sperm (or with your own if your count, shape, and motility are not too abnormal), or intracytoplasmic sperm injection (ICSI).

Treating Premature Ejaculation With Kegel Exercises

August 25, 2013

Historically Kegel exercises have been used by women for the treatment of urinary incontinence.  Kegel exercises can be performed by both men and women to strengthen the pelvic area, but men who are experiencing premature ejaculation can perform Kegels to delay ejaculation and enjoy a better sexual experience. 

 

What Are Kegel Exercises?

Kegel exercises are a set of pelvic floor exercises that help men maintain penile fitness.  Men who are interested in ejaculating with force and better control can learn to control their pelvic and Kegel muscles by squeezing them gently while they have an erection.  Controlling ejaculation, erections and orgasms can be a challenging process, but men who are disciplined enough to strengthen their Kegel muscles can learn how to control their ejaculation and enjoy a more fulfilling sexual experience.

Reverse Kegels are a special type of Kegel exercises that help men maintain a longer erection and enjoy a more intense orgasm and gain control of the ejaculation process. These exercises are most suitable or men who are dealing with premature ejaculation.

 

Performing Kegel Exercises For Men

Find a quiet and private place to practice your reverse kegels.  You’ll need to take your time when you first begin.  You’ll need to settle into a place without any interruptions.  Then, you will need to:

1.  Relax the penile area completely and clear your mind of tension and anxiety.  You want to be calm and relaxed so that the blood can flow into your penis.

2.  Begin contracting the penile muscles.  Focus on contracting the muscles near the front of your penis while keeping the rest of the pelvic area as relaxed as possible.  The goal is to make your penis become stronger and more erect without actually having an erection.

3.  Breathe deeply and slowly as you push out the muscles in the penile area and maintain focus on strengthening only the top and lower end of the penis.  Take note of how relaxed and loose the muscles directly under your penis are.

4.  Let go of the contraction and breathe more deeply as you exhale.  Let your penis relax, then take another deep breath and contract again.  Make sure you are only focusing on the front of your penis; push out, hold for a few seconds, then relax the muscles.

5.  Repeat the cycle for at least 10-15 times per session so that you feel comfortable with the movement.  The entire process will feel awkward at first, but it’s very important to focus on relaxation and keeping the muscles as loose as possible outside of the contractions.  You can work your way up to 40-50 exercises per session as your penis becomes stronger.

Other Information About Reverse Kegels

Kegel exercises can take time to master, but it’s important to practice them at least a few times per week to learn the best technique that works for you.  You will need to relax the entire penile area in order to let the blood flow naturally before beginning the exercises.  It’s important to focus on being very calm and relaxed so that there is no tension or stress built up in the area; after a few days of successfully performing the exercises, you’ll feel that the area is much looser, stronger and you have a much better sense of control of the ejaculation and erection process.

Other Benefits of Kegel Exercises

Most people undertake Kegel exercises for a more satisfying sex life; when a partner can maintain a longer erection, the act of love making can be a more sensual and satisfying experience.   Kegel exercises may also give men more confidence in the bedroom.  Performing Kegel exercises regularly may also reduce the risk of prostate cancer in some men; an unhealthy prostate typically results from a poor diet and inefficient circulation in the penile area.  Kegel exercises can help to keep the prostate healthy and performing at its optimal level.

 

Bottom Line: Premature ejaculation is a common problem affecting many sexually active men.  Kegel exercises are a non-invasive, non-medical solution.  It’s inexpensive, can be done almost anywhere and does have favorable results. 

To PSA or not to PSA…that is the questio-Everything you wanted to know about PSA and not afraid to ask?

August 21, 2013

John Doe is 55 years old. He has no urinary symptoms. He goes for his annual physical exam. His prostate exam is normal, but his prostate specific antigen (PSA) blood test is 4.5, which is slightly elevated. His last PSA test was 2 years ago, and at that time it was 2.7. He is referred to a urologist and a discussion takes place regarding whether he should proceed to a prostate gland biopsy based upon this elevated PSA. What is he to do? This chapter will review the background of the PSA test. What is it’s purpose, and how it is used to make decisions regarding the diagnosis, evaluation and management of men with prostate issues and prostate cancer.

PSA is the most useful and accurate cancer marker of all the cancer “markers” used in medicine today. This statement is of almost universal agreement among physicians and researchers working in cancer treatment and research. Some of you may find that statement a bit startling in light of all the negative press that has appeared regarding the PSA test in recent history. Lets define then what is meant by a “marker.” This is different than cancer screening” which has actually been where the controversy surrounding PSA has arisen. A marker for a tumor is “A substance that can be detected in higher than normal amounts in the blood, urine, or body tissues of some patients with certain types of cancer.” (medterms.com) Other examples of tumor markers include CEA in the case of some gastrointestinal tumors, CA-125 as a marker in ovarian cancer, Beta-HCG and alpha-fetoprotein in some testicular tumors, and even abnormal cells found in a Pap smear used to detect cervical cancer in women.

But as markers go, the PSA test, in a patient diagnosed WITH prostate cancer (PCa), no marker is superior in monitoring the progress and even prognosis of a PCa patient as is the PSA test.

HISTORY OF PSA

It may seem as if we have always used the PSA test in screening for, and in evaluation and follow-up of men with prostate cancer, but its usefulness in this arena is actually of fairly recent onset. There is no question that the discovery of this tiny molecule has dramatically, and forever changed the playing field in the world of PCa.

Before the discovery of PSA the world of screening for, and of attempting to make an early and timely diagnosis of prostate cancer was entirely different. In the pre-PSA era, and this includes all the years prior to the late 1980’s and early 1990’s when PSA became clinically useful, it was very difficult for clinicians to diagnose PCa in a stage where it could be cured by the therapies of that time. Prior to the use of PSA as a screening tool, all we clinicians had at our disposal was our digital exam, our level of suspicion based upon a family history, and to some extent, a blood test called Prostatic Acid Phosphatase, or PAP. Unfortunately, in a large number of men eventually diagnosed by one of these methods, the cancer had often spread beyond the prostate, and hence, was incurable by the technologies of the time.

As strange as it may sound, the actual discovery of PSA is clouded in controversy, and it seems several scientists have been called the discoverers. PSA seems to have been first identified in he U.S., by Dr. Richard Ablin and his associates as early as 1970. A subsequent article by Dr. Ming Wang was published in 1979, and this has often has been cited, apparently incorrectly, as the first scientific article cited as the “discovery” of PSA. This 1979 publication however, was the first to advance the idea that the PSA test could purified and could be useful in detection of prostate cancer. At this point, research was then directed towards developing a commercially usable, reliable, reproducible, and reasonably priced blood test that could be made available to the public.

Some of the very early developmental research for PSA was on it’s presence in semen and to assess it’s properties and usefulness as a forensic marker for rape victims. Soon however, the usefulness of PSA as a screening tool for prostate cancer became quite evident, and as they say, “the rest is history.”

As early as 1981 research was demonstrating significant differences in the blood PSA levels in patients with benign, non-cancerous prostate enlargement (BPH) as opposed to men with prostate cancer. In addition, research in the early 1980’s was demonstrating that men with more advanced prostate cancers had higher blood levels of PSA than men with less advanced cancer.

So, as literally millions of data points were studied, what then is accepted as a “normal” PSA. The very simple answer is up to 4 nannograms per milliliter, or 4ng/ml. It’s never really that simple however. There are many nuances the physician must consider when evaluating a man and his PSA. For example a PSA of 3 in a man of 50 might be worrisome, where a PSA of 5 in a 75 year old man might not be. Change over time can be important. A man whose PSA went from 1 to 3 in one year, both “normal” numbers, might be more worrisome for cancer than a man who has had PSA’s between 5 and 7 over the past 10 years. More on this later, but for most lab reports you will see “normal” for PSA as between zero and 4.

During this same timeframe it was becoming apparent that men who had undergone curative treatment for prostate cancer had PSA levels close to zero, and that if the cancer reappeared, the PSA levels began to climb, making the test very useful in following, or monitoring patients to detect failure or success of treatment. In addition, it became clear that a rise in PSA could be seen usually long before the location of the recurrence could be detected by other means.

Despite all this favorable research data accumulating in the early 1980’s, PSA was originally approved by the FDA in 1986 to monitor the progression of prostate cancer in men who were diagnosed with the cancer. It may surprise you that it was not until 1994 that the FDA approved the PSA blood test , along with a digital rectal exam (DRE), to screen men without symptoms, for prostate cancer. Clearly, over this two decade period, screening for cancer with PSA and DRE has become commonplace in medicine.

Things have now gone backwards in the eyes of many clinicians, in that NOW, another governmental agency, the U.S. Preventive Task Force (USPSTF) recommends AGAINST prostate cancer screening. More on this controversial move, to follow.

Since PSA has dramatically changed our approach to screening for, diagnosing, and monitoring prostate cancer, what has changed in the two decades since this approach has been in full swing? The incidence rates for PCa took a significant upturn at the same time PSA test was approved by the FDA, and even before it was FDA-approved for screening of asymptomatic men. Clearly, clinicians recognized its utility for screening before it was “officially” approved for this particular use. The incidence rates of prostate cancer remain much higher than it was in the pre-PSA era. This is a reflection of our ability to diagnose the disease much earlier now, and not due to an actual increase in the true incidence of the disease in our society. One of the arguments of proponents of “non-screening” with PSA is that many more men are being diagnosed with cancer that might never have impacted their lives had it never been detected. More on this later.

Along with improved early detection brought on by the advent of PSA, the death rates have also begun to fall. This would certainly be anticipated. If we can diagnose cancer, or for that matter, almost any medical condition, before it is far advanced, our chances of cure or survival are enhanced. Death rates, calculated as rates per 100,000 males was rising slowly from about 1940 until about 1985 when the death rate took a spike through about 1995, and has fallen steadily over the past 20 years or so.

The number of men dying in the U.S. yearly from PCa is a little over 30,000. Many clinicians involved in studying this disease feel that if these men who die of the disease had been seeing a physician yearly, and had been undergoing appropriate screening we might be able to drop this number of deaths perhaps as much as 90%. Even with appropriate screening, and let’s say even if 100% of men over the age of 50, could be screened yearly for PCa, there would still be some deaths from the disease. Some men, albeit a small percentage, will develop a form of prostate cancer that is so aggressive and virulent, that even with the best treatments available to us today, we still cannot cure them.

Since it is intuitively clear to all of us, that early diagnosis of disease is good, and we all now know the wonderful utility of the PSA test in early detection of PCa, why has the test gotten so much negative publicity? In fact, if you have been watching, there has been almost no positive publicity in the past few years, but there has been an onslaught of negative. We physicians are asked daily now by our patients as to why there is this negativity, and then whether they should be doing the test. More about how to make the decision to test, or screen, for prostate cancer. Some guidelines to help you in this decision will follow in soon in this chapter.

We will look into the science, and some would call it “junk science” behind the recommendations of the U.S. Preventive Services Task Force recommendations against screening for prostate cancer, but let’s first take a look at some of the “politics” if you will, of cancer screening in general, as this puts a lot of it into a perspective we can all understand. A lot of this seems to be driven by finances on both a private, federal, and state level. Since a large portion of the costs of cancer screening is borne by governmental agencies, and most of the rest, by private insurance, the costs have to be taken into consideration. Now, for the thousands, or millions of Americans whose lives have been saved by early detection, and cure of their own bout with cancer, these cost issues seem quite secondary to them, and to their loved ones. They know cancer screening saves lives. They are living proof.

To actuaries looking from under their green eye shades at the numbers, screening for cancer, regardless of the lives saved, does not make good policy or financial sense. And, they would say arguably, the costs are not sustainable. We all know Medicare is going broke, despite the fact that any of us who have a job, and are receiving a paycheck, are paying not only for the private insurance we are using now, but also Medicare premiums are being taken out of every paycheck. So where does screening for cancer fit in this financial mileu?

Several cancers have taken a hit lately. Screening mammograms for early detection of breast cancer in women came under fire recently. Women rose up, and the government and insurance companies backed off. Screening for cervical cancer has come under fire, and the recommendation for screening for colon cancer, largely under the radar, has changed too. Will lives be lost? Will failure to detect early cost us in suffering and early demise of untold Americans? Of course. But in a dollars and cents world, screening for cancer is just too expensive. Let’s take a somewhat imaginary look at the numbers before we look at the USPSTF recommendations in detail.

Let us imagine a million men being screened annually for prostate cancer. Since the numbers used here are estimates, they are going to be off a little from what might be absolutely correct, but since the actual numbers are not obtainable, the numbers we use here at least give us a reasonably accurate framework. And this is done, only to try and put the costs of cancer screening into perspective.

So, back to our one million men being screening annually for PCa. Let’s suppose that this could be done for about $75.00 to include a doctor visit, the exam, and the blood test. Right away we have consumed 75 million dollars. Let’s say that of those million men, everything is normal for 800,000 of them-probably a reasonable estimate. We are through with them for this year. Now of the remaining men something in the exam, the blood test, or the medical history is concerning. The doctor has a concern that these men might have cancer. For those being screened by their primary provider, a consult with a urologist will be needed. Some of these men will be seeing a urologist for their yearly screening, but the others will have to be referred. Let’s say conservatively that of these 200,000 men, 50,000 will need a new and initial consultation with a urologist, and the cost could be around $100.00 for this initial consultation. $5,000,000 there. Some will go to immediate biopsy, but let’s say the doctors decide not to do a biopsy on half of the men, but simply to recheck them, and obtain another blood test in couple months. These would be the men for whom the urologist is not highly suspicious for cancer, but they still will need to be followed appropriately. Another couple million for the second visit and testing of blood for PSA. Now let’s suppose that out of the one million men being screened, only 1% are ultimately thought to need a biopsy. That would be 10,000 men times a conservative cost for biopsy of $1,000.00. Another $ 10,000,000 dollars for the biopsies. Now if 1 in 4 had a positive biopsy, probably 3 in 4 with cancer would need treatment. Millions and millions have been spent before treatment has even started.

So, using these numbers, which are reasonable, the screening costs for 1 million men is easily in the neighborhood of $100,000,000. Now, what if we are trying to screen 5 million men, or 10 million men, or more, yearly? You can see how this adds up to astronomical numbers. And this is only for one cancer. We have not even looked at screening for breast, colon and lung cancers which make up the rest of the “big four.”

With this financial meltdown facing health insurance providers one can see why screening for cancer has become such an issue, and perhaps these numbers factor into some of the decision making processes.

Let us now take a look at the Draft Recommendation Statement from the USPSTF. First, at this time, it is a draft. More will come. If you care to review it in detail, it is available at http://www.uspreventiveservicestaskforce.org/prostate/prostateart.htm.

However, the salient points will be reviewed for you here. Quoting, “The USPSTF makes recommendations about the effectiveness of specific clinical preventive services without related signs or symptoms.” Keeping in mind here, by the time a man has symptoms or signs of PCa, the cancer has spread beyond the prostate and is no longer curable.

Quoting: “Summary of Recommendation and Evidence. The U.S. Preventive Services Task force (USPSTF) recommends against prostate-specific-antigen(PSA)-based screening for prostate cancer. This is a grade D recommendation.”

What is a grade D recommendation? If you ever got a grade of D in school, you know it is not good! Specifically, the definition is: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that harms outweigh the benefits. Their “Suggestions for Practice” here regarding screening for prostate cancer with the D rating, “Discourage the use of this service.”

Quoting further from the draft document:

“Prostate cancer is the most commonly diagnosed nonskin cancer in men in the the United States, with a lifetime risk of diagnosis currently estimated at 15.9%. Most cases of prostate cancer have a good prognosis, but some are aggressive; the lifetime risk of dying from prostate cancer is 2.8%. Prostate cancer is rare before age 50 years and very few men die of prostate cancer before age 60 years. The majority of deaths due to prostate cancer occur after age 75 years.”

Let’s take a quick look at this 2.8% risk of dying from prostate cancer. About 238,590 new cases will be diagnosed in the U.S. in 2013, and about 29,720 men die of this cancer in 2013 according to the National Cancer Institute estimates. It would appear from these numbers that the risk of dying from prostate cancer easily exceeds 10%.

The draft document goes on further to elaborate on harms of detection and early intervention to include risks associated with biopsy itself, the adverse effects of treatments be they surgery or radiation or hormone deprivation. Another risk is “overdiagnosis.” This, the panel seems to believe, results in many men being treated for cancer that never would impact their lives. Now since urologists and oncologists treating prostate cancer make every effort not to overtreat the insignificant cancers, we have to wonder what exactly is meant by this? As they were quoted above, “some of these cancers are aggressive,” is there a way to know which type (aggressive vs. non-aggressive) without a diagnosis? Do we as physicians owe it to our patients to help them make decisions for treatment based upon the best evidence we can provide? In most cases, one would answer yes to that question.

There is no doubt this panel put a monumental amount of time and effort into this document, and the conclusions they came to were based upon the evidence they felt was significant. They reviewed at least three large trials regarding prostate cancer, one called the PLCO, another, from Europe. The ERSPC trial, and the preliminary results from the PIVOT trial.

The USPSTF estimates that for every 1,000 men ages 55 to 69 who are screened every one to four years for a ten year period that only a maximum of one death from prostate cancer would be avoided. Using our estimated numbers above, this means it would cost about $1,000,000.00 to save one life. If this is true. There are other ways to run these numbers, and you mathematicians can have a field day with them, but you can see again, screening for cancer is very costly. Now we as physicians don’t see 1,000 men at a time, we see individual men just like you, and together you and I have to try and make our best decisions for your individual health. More on that decision making process later on.

On May 21, 2012, the USPSTF released it’s Final Recommendations of PSA Screening, and the final document confirmed what was said in the draft.

Urologists are at the forefront of being tasked with diagnosing, and in most cases, treating men with prostate cancer. We work closely with our oncology colleagues in men with very advanced cancer. The American Urological Association (AUA) has spoken out against the USPSTF recommendations.

The AUA’s position is one of outrage regarding the USPSTF position and takes the position that the Task Force “is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease. We hold true to our current position s supported by the AUA’s Prostate Specific Antigen Best Practices Statement that, when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients.”

(Further 2013 position to be presented in May-will be elaborated here)

So, how are we, as men, to make decisions regarding PSA screening as it fits into our own individual lifestyle, expectations, and plans for our own medical futures?

In simplest terms, if you and your physician feel that if you are screened for PCa it would help you make decisions about the direction you would want to take if you were in fact diagnosed with prostate cancer, then screening is probably a wise step to take.

Let’s keep in mind a few facts. It is clear that PSA screening does reduce mortality from prostate cancer compared to men who are not screened. It is also true that screening has led to a diagnosis of PCa in men in whom the disease might never had caused problems. Many of these men were nonetheless, treated, hence “overtreatment.” It is also true that we as clinicians have gotten much better at helping to cull out those insignificant cancers and counseling our patients accordingly. It is also true that biopsy does carry some risk, albeit small, of serious infection. A small number of men, in our experience, less than 1% will require extended antibiotic therapy after a biopsy, and a few may even end up spending a few days in the hospital for post-biopsy fever and infection. It is also true that some men who are treated for prostate cancer will suffer adverse effects including incontinence, erectile dysfunction and bladder dysfunction. It is also true, that nearly all men who may have these effects can be adequately treated for these adverse consequences.

So, who should be screened? A life expectancy of 10 years is often used as a guideline. Clearly we don’t know how long we will live at any given time, but a very healthy 75 year old man might benefit from screening far more than a 60 year old man who has had a heart attack, bypass surgery, diabetes, high blood pressure and obesity. Now that 60 year old might live to a ripe old age, and that “healthy” 75 year old might have that fatal heart attack tomorrow. Hence, the dilemma we all face-patients and physicians alike. But we try to be as practical here as we can. But if you as a male patient feel that you would want to be in a position to make decisions regarding prostate cancer treatment if you were to be diagnosed, then the decision to screen is likely in your best interest. Our advice is to have this discussion with your physician before screening for prostate cancer.

HOW CAN WE IMPROVE SCREENING FOR PROSTATE CANCER?

With regards to PSA screening, what is on the horizon, and what do we have now to further refine and tighten our accuracy of screening for PCa?

Now that so much progress has been made with DNA and in clarifying the human genome, it seems likely that in the not to distant future, genetic identification of those either at high risk, or that in fact WILL develop prostate cancer seems plausible. We are not there yet.

From the National Cancer Institute, here are some ways that scientists and researchers are looking to improve PSA screening.

Free versus total PSA: The lower the free PSA is a percentage of total PSA the more likelihood of finding cancer, and a very low free PSA may be associated with more aggressive cancer. We like to see a free PSA greater than 25% of total. For example, a man with a total PSA of 5, and a free PSA of 2.5 has a 50% ratio. His likelihood of PCa is low (not zero though) Whereas the man with a total PSA of 5, and a free of 0.4 has a ratio of 8%, and his risk for having PCa right now is high. This is useful test, but not perfect.

PSA density of the transitional zone: To gather this information requires ultrasound measurements of the prostate, and though perhaps more accurate than PSA alone, this approach has not been fully validated.

Age-specific PSA reference ranges: Unless a man is taking medication to shrink the prostate, dutasteride or finasteride, the prostate grows a little each year. Hence there are more prostate cells to produce PSA. As a result, a “normal” PSA in a man of 70 may be different that “normal” at age 50. This approach lacks general acceptance in the urological community however, since its use may delay a diagnosis of PCa.

PSA velocity and PSA doubling time: You will recall earlier in this chapter we discussed the man whose PSA went from 1 to 3, as being perhaps more worrisome than a man with a PSA between 5 and 7 while being followed for a decade. Quoting from the National Cancer Institute, “Some evidence suggests that the rate of increase in a man’s PSA level may be helpful in predicting whether he has prostate cancer.”

Pro-PSA: There is quite a lot of work being done looking at these different inactive precursors of PSA, and there is some evidence that pro-PSA may be a better predictor, and hence a better screening methodology than PSA as we are using it today. This is not yet ready for “primetime” yet.

PCa3: This test is readily available for clinical use today, and has a place in our screening toolbox. PCa3 is a chemical produced in the prostate gland. In order to do the test, the physician must put a little pressure on the prostate while doing the digital rectal exam. This pushes a little prostate fluid into the urethra. The patient is then asked to urinate, and the first ounce or so of urine will contain that prostate fluid. This sample is then sent to a specialized lab capable of doing the test. If PCa3 is present in this urine sample, depending upon the degree, the risk of prostate cancer can be further elucidated. The nee for a biopsy can be refined depending upon the result of the PCa3.

One other approach that is receiving increased incidence we will mention only briefly here since this chapter is about PSA, but is being looked at as a screening tool for prostate cancer. This is not a blood test, but an imaging study. Prostate MRI with a powerful 3 tesla MRI machine has shown usefulness in imaging cancer with considerable accuracy within the prostate gland itself.

DEFINITIVELY DIAGNOSING PROSTATE CANCER:

As the science of prostate cancer diagnosis stands today, biopsy remains the only definitive way to make the diagnosis. There are a couple caveats here-a man with a PSA over 100 probably does not need a biopsy. A man who has on X-Ray definitive evidence of cancer in his bones, and a high PSA many not need a biopsy. However, this chapter is about screening, and especially screening in the man with no symptoms. In that man, biopsy of the prostate remains the final diagnostic test. The use of PSA and the other modalities mentioned above serve mostly to help the physician and the patient decide as to whether proceeding on to biopsy is indicated. We are trying to refine screening so that we will be able to avoid biopsy in many men because, as a result of screening tests, we can reasonably believe our patient does NOT have prostate cancer.

As is clear to all of you now, having read these pages, PSA remains an extremely valuable tool in our cancer screening toolbox. How it can be useful in the case of each individual patient remains just that, individual. With the information we hope you have gained in this chapter, you will hopefully be in a better position to understand the usefulness as well as the limitations of PSA screening. Hopefully the decision making process will be clearer to you as you have discussions with your physician regarding PSA screening for prostate cancer. For many of you, it will be quite simple. If for example, you are a healthy man between 50 and 70 years of age, and you already know that whether you have PCa matters to you so that you can make proper decisions, doing the test is a slam-dunk. This would include a wide swath of men. For some, it will not be so simple, and many factors will have to be considered prior to screening. We hope this chapter has helped.

Let’s go back to our patient described at the beginning of the blog: He is 55 years old, having no urinary symptoms and is in for his physical. His prostate exam is normal, but his PSA is slightly elevated at 4.5. Last year he did not have an exam, but two years ago it was 2.7. He is referred to a urologist and a discussion takes place regarding whether he should proceed to prostate gland biopsy. What should he do? What would you want to do it this was your data? Hopefully, you now have some parameters to help you make the decision in your own individual situation.

Impotence or Erectile Dysfunction Can Affect More Than Your Bedroom Activities

August 21, 2013

Impotence It’s reversible
Nearly 50% of all men have a problem obtaining and maintaining an erection adequate for vaginal penetration. Having an occasional problem getting or keeping an erection is normal. But when it happens most of time and it’s severe that you cannot achieve an erection adequate for penetration, it’s time to consult with your physician

But erection issues aren’t only a problem in the bedroom, there is now strong evidence they are “a dangling stress test” – a warning sign you may high cholesterol, high blood pressure, diabetes or damaged arteries that may increase your risk of heart attacks.
When I went to medical school in the late 1960’s most erection problems were thought to be psychological and 20 per cent physical. We now know it’s probably the other way around and that 80% are due to physical causes and less than 20% are due to psychological causes. There are some clearly psychological causes of sexual problems but they’re the minority overall. There are often some pretty clear clues as to whether the problem is psychological; probably the one that clearly suggests that the problem is psychologic is that the man gets an erection upon awakening in the morning. Men with psychological impotence are able to get an erection with self-stimulation or masturbation. And finally, men with psychological erections will state that they can get an erection with another woman but not with their wife or regular partner.

Usually if it’s a physical issue, it will affect erections occurring at all times – whether they’re spontaneous, masturbatory or provoked erections. In men with severe erection problems, it’s nearly always physical.

Many men get a lot of comfort from knowing this is a medical problem. I think it helps men to know ED is just another symptom, like trouble with urination or something else that’s indicative there may be some physical disease going on and it needs to be assessed, rather than something wrong with their masculinity. It is important to mention that a physical cause can lead to secondary psychological problems too.

At any age there can be a specific cause, it might be drug or alcohol abuse, it might be prostate cancer, it could be a drug for treating high blood pressure or it could be low testosterone, the male hormone produced in the testicles that is responsible primarily for the sex drive or libido.
But as men move through their 40s, 50s, 60s, there’s also an increase in the prevalence of ED and in a big portion of this group it’s frequently a vascular [blood vessel] problem.

It’s not so much that there’s necessarily heart disease at that point, but the factors that lead to heart disease are now starting to show up in the penis. The blood supply to the heart is through blood vessels that 6-8mm in diameter. The blood vessels that supply the penis are only 3-4 mm in diameter. Therefore if the man has a condition that narrows the blood vessels such as atherosclerosis, the penis will be affected before the heart. That is why erectile dysfunction will often occur years before a man has a heart attack. In a sense, the penis is a barometer because to get an erection and maintain it, you need to increase the blood flow by about 10 or even 15 times. There’s no other organ in the body like that. So if you’ve got minor things affecting the vascular system, it will show up in the penis.

There’s strong evidence if you develop ED in your 30s, 40s and 50s, you’re at greater risk of having a heart event over next five years. Even minor erectile problems could be an indicator of future heart risks. I wouldn’t say if you’ve got ED you should be sitting there thinking, “oh I’ve got heart disease “, although that could be the case.
If you are experiencing ED, begin by consulting with your doctor. Your doctor will test you for diabetes, high blood pressure, and elevated cholesterol levels. There are a lot of lifestyle issues, which when dealt with there and then might have a big effect of reducing the risk of heart disease [or its progression] and possibly restore erectile function. Early intervention will potentially lead to better sexual function because you get a better responsiveness to drugs such Viagra, Levitra, or Cialis which can improve erections].
Use it or lose it. Once the penis has been inactive for a length of time, it gets changes in its structure. These make the tissues less malleable so it’s harder to maintain an erection. You don’t have to be having sex, just having an erection to prevent these changes in the tissues of the penis. Any erection has a value in that it’s oxygenating and stretching out the penis and [this] allows it to work at its best.

Bottom Line: Don’t be in denial, not a river in Egypt, if you are experiencing ED. There is likely an underlying problem that needs your attention. See your doctor, identify the problem, and get treatment. Your penis and your partner will thank you!

Propecia May Make More Than Your Hair Fall

August 21, 2013

Propecia containing finasteride is used for controlling male pattern baldness or hair loss. New data is now appearing that suggests that the use of Propecia may result in sexual side effects such as erectile dysfunction or impotence, decreased libido or sex drive, and male infertility. Even after discontinuing the use of Propecia, the side effects can last for up to three months.

What is more frightening is that a study from Sweden showed that users of Propecia could experience permanent erectile dysfunction. In 2012, the Journal of Sexual Medicine found that almost 96 percent of men reported some Propecia sexual dysfunction for more than a year after usage, and 20 percent experienced sexual side effects for more than six years.
So what is man who is losing his hair to do? I suggest that you speak to your primary care physician or your dermatologist and discuss these side effects. If you are currently taking the medication and are experiencing sexual side effects such as decreased libido or erectile dysfunction, I suggest you consider discounting the medication.

Fertility-Steps To Improve Your Chances

August 21, 2013

Common Causes of Infertility in Men

Hoping for a child

Hoping for a child


About 10 percent of reproductive-age couples in the United States will have difficulty getting pregnant. About 30 percent of cases are due to fertility problems in the man, 30 percent to fertility problems in the woman, and the rest to unexplained causes or multiple factors involving both partners.

If you’ve had regular, unprotected sex for more than a year (or six months if you’re over 35) without conceiving, see your doctor. The National Infertility Association says at least half of those who have an infertility evaluation and treatment will be able to have a successful pregnancy.

A reproductive urologist can identify male fertility issues, recommend treatment options, and help couples decide which options to pursue. You also may want to see a genetic counselor. Sometimes, there’s a genetic reason for male infertility that could be passed down to children. A genetic counselor can help couples understand their options for conceiving.

Read on to learn about the common causes of infertility and available treatments. Keep in mind that success rates may vary because one couple can have multiple fertility problems.

Lifestyle factors. Making healthy choices can improve your fertility. You may be at greater risk of having trouble conceiving if you:

Smoking can be deleterious to your fertility

Smoking can be deleterious to your fertility

• Smoke;
• Drink alcohol heavily; Use drugs;
• Take anabolic steroids;
• Take certain medications, including testosterone replacement therapy;
• Have been treated for cancer;
• Have poor nutrition;
• Are significantly over- or underweight;
• Are exposed to toxins, such as pesticides or lead.

If you have any of these risk factors, be sure to tell us about it during your consultation.

Blockages. A small percentage of men have a blockage in their ejaculatory duct that prevents sperm from getting into ejaculate fluid. If your vas deferens or epididymis tubes are blocked or damaged, they can prevent your sperm from getting to your partner’s egg. Infection, injury, congenital defects, or a vasectomy could cause this blockage.
• Possible solutions: Surgery to repair an obstruction or reverse the vasectomy, or surgery to remove sperm for in vitro fertilization (IVF).

Varicocele. Varicoceles (enlarged veins, similar to varicose veins, in the scrotum) raise the temperature in the testes, which may affect sperm production.
Possible symptoms: Some men have scrotal pain, and others have no symptoms. (The problem can be detected through a physical exam or ultrasound.)
Possible solutions: Surgery to repair the varicocele, artificial insemination, or IVF.

Sperm making contact with egg

Sperm making contact with egg


Irregular sperm. If you have little to no sperm, poor sperm motility (ability to move), or abnormally shaped sperm, your sperm may not be able to fertilize your partner’s eggs.
Possible solutions: fertility drugs; artificial insemination with donor sperm (or with your own if your count, shape, and motility are not too abnormal), or intracytoplasmic sperm injection (ICSI).

11 Things to do Before School Starts

August 21, 2013

1. Good physical and mental health. Be sure your child is in good physical and mental health. Schedule doctor and dental checkups early.
2. Review all of the information. Review the material sent by the school as soon as it arrives.
3. Mark your calendar. Make a note of important dates, especially back-to-school nights. This is especially important if you have children in more than one school and need to juggle obligations.
4. Make copies. Make copies of all your child’s health and emergency information for reference.
5. Buy school supplies early. Try to get the supplies as early as possible and fill the backpacks a week or two before school starts.
6. Re-establish the bedtime and mealtime routines. Plan to re-establish the bedtime and mealtime routines (especially breakfast) at least 1 week before school starts.
7. Turn off the TV. Encourage your child to play quiet games, do puzzles, flash cards, color, or read as early morning activities instead of watching television.
8. Visit school with your child. If your child is young or in a new school, visit the school with your child. Meeting the teacher, locating their classroom, locker, lunchroom, etc., will help ease pre-school anxieties.
9. Minimize clothes shopping woes. Buy only the essentials. Summer clothes are usually fine during the early fall, but be sure to have at least one pair of sturdy shoes.
10. Select a spot to keep backpacks and lunch boxes. Designate a spot for your children to place their school belongings as well as a place to put important notices and information sent home for you to see.
11. Freeze a few easy dinners. It will be much easier on you if you have dinner prepared so that meal preparation will not add to household tensions during the first week of school.

7 Ways to Cancer-Proof Your Body

August 21, 2013

Recent research reveals 7 stealth strategies to keep the killer at bay. It’s time to raise your carcinogen shields—and your overall health—using these smart anti-C tips.

1. Drink pomegranate juice. 
Some say this luscious, lusty red fruit is Eve’s original apple, but what the pomegranate truly banishes is cancer risk. The fruit’s deep red juice contains polyphenols, isoflavones, and ellagic acid, elements researchers believe make up a potent anticancer combo. It’s been shown to delay the growth of prostate cancer in mice, and it stabilizes PSA levels in men who’ve been treated for prostate cancer.

pomegranate juice

pomegranate juice


2. Eat blueberries. 
 Got pterostilbene? Rutgers University researchers say this compound—found in blueberries—has colon cancer-fighting properties. When rats with colon cancer were fed a diet supplemented with pterostilbene, they had 57 percent fewer precancerous lesions after 8 weeks than rats not given the compound did. Eat blueberries and you’ll also benefit from a big dose of vitamin C (14 milligrams per cup).

3. Relax a little. 
 Purdue University researchers tracked 1,600 men over 12 years and found that half of those with increasing levels of worry died during the study period. Talk about flunking the exam. Only 20 percent of the optimists died before the 12-year study was completed. More anxiety-producing news: Thirty-four percent of the neurotic men died of some type of cancer.

4. Take Selenium. Selenium has long been thought of as a cancer fighter, but you can have too much of a good thing. A study of almost 1,000 men, published in the Journal of the National Cancer Institute, found that when those with the lowest initial levels of selenium in their bodies received a daily supplement over a 4 1/2- year period, they cut their prostate-cancer risk by an impressive 92 percent.

5. Vitamin D every day. 
Scientists have viewed vitamin D as a potent cancer fighter for decades, but there’s never been a gold-standard trial—until now. A Creighton University study published in the American Journal of Clinical Nutrition found that women who supplemented their diets with 1,000 international units of vitamin D every day had a 60 percent to 77 percent lower incidence of cancer over a 4-year period than did women taking a placebo. Vitamin D is necessary for the best functioning of the immune system—it causes early death of cancer cells.



6. Clear your air. 
Secondhand smoke may be even worse for you than we thought. A recent American Journal of Public Health study reveals that nonsmokers working in smoky places had three times the amount of NNK, a carcinogen, in their urine than nonsmoking workers in smoke-free joints had. And their levels of NNK rose 6 percent for every hour worked. There is no safe level of exposure to secondhand smoke, and the greater the exposure, the higher the risk.

7. Invest a little sweat equity. 
Study after study has pointed to the cancer-beating power of exercise. Now research from Norway has found that even a tiny dose of exercise has big benefits. A study of 29,110 men published last year in the International Journal of Cancer shows that men who exercised just once a week had a 30 percent lower risk of metastatic prostate cancer than did men who didn’t work out at all. Increasing the frequency, duration, and intensity of the exercise correlated with a further, gradual reduction in risk.